Melanoma of the head and neck

Importance of sentinel lymph node biopsy in patients with thin melanoma

HYPOTHESIS

The status of the sentinel node (SN) confers important prognostic information for patients with thin melanoma.

DESIGN, SETTING, AND PATIENTS

We queried our melanoma database to identify patients undergoing sentinel lymph node biopsy for thin (< or =1.00-mm) cutaneous melanoma at a tertiary care cancer institute. Slides of tumor-positive SNs were reviewed by a melanoma pathologist to confirm nodal status and intranodal tumor burden, defined as isolated tumor cells, micrometastasis, or macrometastasis (< or =0.20, 0.21-2.00, or >2.00 mm, respectively). Nodal status was correlated with patient age and primary tumor depth (< or = 0.25, 0.26-0.50, 0.51-0.75, or 0.76-1.00 mm). Survival was determined by log-rank test.

MAIN OUTCOME MEASURES

Disease-free and melanoma-specific survival.

RESULTS

Of 1592 patients who underwent sentinel lymph node biopsy from 1991 to 2004, 631 (40%) had thin melanomas; 31 of the 631 patients (5%) had a tumor-positive SN. At a median follow-up of 57 months for the 631 patients, the mean (SD) 10-year rate of disease-free survival was 96% (1%) vs 54% (10%) for patients with tumor-negative vs tumor-positive SNs, respectively (P < .001); the mean (SD) 10-year rate of melanoma-specific survival was 98% (1%) vs 83% (8%), respectively (P < .001). Tumor-positive SNs were more common in patients aged 50 years and younger (P = .04). The SN status maintained importance on multivariate analysis for both disease-free survival (P < .001) and melanoma-specific survival (P < .001).

CONCLUSIONS

The status of the SN is significantly linked to survival in patients with thin melanoma. Therefore, sentinel lymph node biopsy should be considered to obtain complete prognostic information.

Controversies in the management of metastatic melanoma to regional lymphatic basins

The primary management of lymph nodes involved with metastatic melanoma is regional lymphadenectomy. Many controversies of regional lymph node dissection exist including extent and nature of the lymphadenectomy, treatment of lymphatic metastases in unusual locations and the role of adjuvant radiotherapy. Although radical neck dissection has been the gold standard for cervical disease, modified dissections do not seem to compromise regional control in appropriately selected patients. In the axilla, a Level I, II, and III dissection is most commonly performed. Combined superficial and deep groin dissection is justified for clinically palpable disease although management of patients with histologically positive yet clinically non-palpable disease is more controversial. Burden of disease, imaging, patient co-morbidity, and Cloquet nodal status must be considered. Many technical variations exist in an attempt to improve morbidity rates secondary to lymphadenectomy. Unfortunately, complication rates are difficult to compare secondary to variable study designs, definitions, and patient populations. Adjuvant radiation therapy appears warranted in patients with high risk of regional recurrence including bulky disease, extracapsular extension or cervical location.

Cutaneous malignant melanoma of the head and neck. Analysis of treatment results and prognostic factors in 581 patients: a report from the Swedish Melanoma Study Group

BACKGROUND

Results of surgical treatment of cutaneous malignant melanoma (CMM) have been highly variable, probably because of patient selection. Therefore, a study of representative patients with this disease was performed.

METHODS

In a defined area of Sweden, 581 patients were analyzed. Clinical records and histopathologic findings were reviewed. The minimum follow-up time was 7 years. Prognostic factors were evaluated by the Cox proportional hazards model.

RESULTS

Evaluation of sex distribution, age, and anatomic site of the primary tumor showed that the patients were representative of all Swedish patients with CMM of the head and neck. The mean patient age at diagnosis was 64 years for both sexes. Fifty-three percent of the patients were women. Female patients had more tumors of the face than did male patients, whereas male patients were overrepresented among patients with tumors of the auricle-external ear canal and scalp-neck area. Localization to the face was observed in 68%, which is an overrepresentation of three to four times when skin surface is taken into consideration. Twenty-four percent of the patients had lentigo maligna melanoma. Only 33% of the patients had superficial spreading melanoma. In univariate analyses, sex, anatomic site of the primary tumor, histogenetic type, Clark level of invasion, and tumor thickness had prognostic power. In a multivariate analysis, tumor thickness, anatomic site of the primary tumor, and sex of the patient were independent prognostic factors.

CONCLUSIONS

In representative patients with CMM of the head and neck, tumor thickness, anatomic site of the primary tumor, and sex of the patients were independent prognostic factors.

Management of nodal metastases from head and neck melanoma

Ninety-three patients with nodal metastases from melanoma (stage II) located in the head and neck underwent surgery at the National Cancer Institute of Milan. Different surgical techniques were employed, ranging from radical to conservative treatment. Analysis of the data shows no significant difference from an oncological standpoint between radical and conservative surgery when a radical dissection is performed. Elective nodal dissections for malignant melanoma of the head and neck region, like those at other sites of lymphatic drainage such as the groin and axilla, did not prove beneficial. We do recommend parotidectomy in cases where the primary tumor arises in the superior area of the head. The number of nodes involved and the type of disease spread constitute the major prognostic factors, as in the case of melanomas located in other sites. Our data further indicate that the incidence of distant and local recurrence is not influenced by the type of dissection performed.

An assessment of neck node immunoreactivity in head and neck cancer

Current conventional forms of cancer treatment represent non-specific modalities that destroy not only cancerous but also non-cancerous tissue in an effort to totally eradicate the neoplasm. It was unknown in head and neck cancer whether a more specific form of treatment, as it relates to neck nodal disease, was advisable. The purpose of this investigation was to study the cervical node immunoreactivity in head and neck cancer patients as a means of determining their immunologic capabilities and thus provide information about the merits of specific vs. non-specific cancer treatment. The results demonstrated that lymphocytes arising from cervical nodes caused alterations in the tumor growth. There appeared to be no particular difference in immunoreactivity of lymphocytes arising from nodes located in different areas of the neck. The regional immune system of neck nodes in the head and neck cancer patient appears to be capable of mounting an immune response irrespective of the patient's tumor status. Usual measures of systemic immunocompetence failed to identify any patients with advanced stage disease and showed little correlation with the regional immunoreactivity. The regional nodal immunoreactivity also did not correlate with the size or the numbers of metastatic neck nodes. The results demonstrate that cervical neck nodes are capable of mounting an immune response to head and neck cancer and are not mere passive filters that are periodically involved with tumor emboli. These results support the need for the development of reliable treatments which are directed at tumor tissue only.

Limited or selective nodal dissection for malignant melanoma of the head and neck

Fifty-eight patients with invasive melanoma of the head and neck underwent regional nodal dissections by one surgeon from 1971 to 1981. Types of nodal dissections employed were radical neck dissection and modified radical neck dissection, alone or in combination, with selective nodal dissection of the parotid, jugular, suprahyoid posterior neck, or posterior triangle lymph node groups. Patients undergoing secondary nodal dissections had early recurrence (9 months versus 30 months) and earlier times of death (26 months versus 41 months). There was no demonstrable difference in morbidity, mortality, or rate of recurrence based on type of nodal dissection. There were no regional failures after selective nodal dissection alone when the nodes removed were negative. This limited study suggests that selective nodal dissection, alone or in conjunction with radical neck dissection or modified radical neck dissection, depending on the location and measurements of the primary lesion, allows accurate pathologic staging and apparent control of local disease with minimal morbidity. Longer follow-up and greater numbers are necessary for valid conclusions.

Melanoma metastatic to the mandible. Report of a case

Metastasis of a tumor to the jaws can simulate an infection, but the presence of paraesthesia and loose teeth or inadequate response to treatment should alert the clinician to a more serious cause. A malignant melanoma metastatic to the jaws illustrates these points.

The use of skin flaps in the treatment of malignant melanomas in the head and neck region

The use of skin flaps in the treatment of malignant melanomas in the head and neck is compared to the application of free skin grafts. In 13 patients the wounds were closed directly, in 58 the defects were covered by free skin grafts, and in 80 patients the defects were covered by flap plasties. The distribution of tumours with various degrees of invasion was similar within the groups. Local recurrences or local skin metastases occurred in 18 patients. Eight were found in the skin graft group. In the group with direct closure only 1 patient had a recurrence. Nine were found in patients treated with skin flaps. The use of skin flaps is often a great advantage from an aesthetic point of view and this survey does not indicate that it is contraindicated for oncologic reasons.

Regional lymph node management and outcome in 100 patients with head and neck melanoma

One hundred patients with invasive melanoma of the head and neck were treated by one surgeon from 1970 to 1978. Lymph node dissections were performed in 77 patients for palpable adenopathy, local recurrence, or tumor thickness greater than 0.75 mm when measured by micrometry. No patient whose lesion was less than 1.0 mm thick had a local recurrence or died as a result of melanoma. Patients who underwent elective lymph node dissection with findings of up to two positive nodes had a 53 to 56 percent 5 year survival rate, while those with three or more nodes had a poor prognosis (15 percent 5 year survival rate). The patterns of recurrence showed that relapse after nodal dissection usually presented with systemic metastases. The data support a therapeutic scheme based on 2 to 5 cm wide excision alone for lesions less than 0.75 mm in thickness and elective nodal dissection for specific indications.

Malignant melanoma patients with positive nodes and relatively good prognoses: microstaging retains prognostic significance in clinical stage I melanoma patients with metastases to regional nodes

Fifteen variables were tested for their value in predicting recurrent disease in 46 clinical Stage I melanoma patients with metastases to regional nodes. A stepwise proportional hazards general linear model (Cox multivariate analysis) separated these melanoma patients with regional node metastases into at least two risk groups. Twenty patients in the relatively low-risk group had a five-year disease-free survival of 80% (in spite of having nodal metastases). This compares to a five-year disease-free survival of 17.5% for 26 patients in the high-risk group (P less than 0.001, Lee-Desu Statistic). Criteria for the high-risk group required that a patient have only one of the following two values: (1) The number of regional lymph nodes that contained tumor divided by the total number of nodes removed x 100% (percentage of positive nodes) greater than or equal to 20%; or (2) a primary tumor thickness of greater than 3.5 mm (regardless of node percentage). Conversely, patients in the low-risk group had neither of the above features. The high-risk group could further be stratified by the lymphocytic response at the base of the tumor. These findings have direct immediate application to the elective regional node dissection controversy and to adjuvant therapy studies containing these patients.

Selective surgical management of cutaneous melanoma of the head and neck

A series of 206 patients with cutaneous melanoma of the head and neck has been studied. Ninety patients had a regional lymph node dissections performed. Seventeen lymph node dissections were done therapeutically and 73 were done electively. Thirty-one patients had histologically positive lymph nodes and, of these, 30 patients have been followed to the present time or death. Twenty-nine of these patients (97%) have developed systemic melanoma. Twenty-six patients have died and three are alive with disease. No patient had local recurrence alone while four had local recurrence synchronously with systemic metastases. This contrasts with 29 patients followed for greater than five years with histologically negative nodes, 27 (93.1%) of whom are alive with no evidence of recurrent disease. Regional node metastases with melanoma of the head and neck is an almost certain indication of systemic disease. A selective surgical approach to invasive melanoma in this region is proposed based on the observation in the 31 patients who had radical neck dissections with histologically positive nodes. The metastases always involved the nodal group adjacent to the primary site. This selective approach should allow optimal local control and accurate pathologic staging while limiting the extent of the surgery.

Value of radiation therapy in the management of patients with cerebral metastases from malignant melanoma: Radiation Therapy Oncology Group Brain Metastases Study I and II

Sixty patients from two Radiation Therapy Oncology Group (RTOG) studies with cerebral metastases from malignant melanoma were analyzed to determine the response to whole brain irradiation. General performance status, neurologic function, and specific neurologic symptoms were evaluated for rate and duration of improvement. Also analyzed was the influence of chemotherapy and steroids, although neither was a controlled factor. Results indicate a significant benefit from radiation therapy in terms of symptomatic and neurologic function improvement. Symptomatic improvement was observed in 76%, with 31% completely improved. Of the four most frequent symptoms, complete or partial improvement was observed as follows: headache--27 of 37 patients (73%); motor loss--14 of 23 patients (61%); impaired mentation--13 of 24 patients (62%); and convulsions--10 of 12 patients (83%). Improvement in neurologic function class was observed in 18 of 44 patients (41%). Median survival for Study 1 patients was 10 weeks (range 1-200) and that of Study II patients 14 weeks (range 1-76). These results are comparable to those found in radiation therapy of brain metastases from all other primary tumors.

Biopsy and prognosis for cutaneous malignant melanomas in clinical stage I

The material comprises 225 patients. In 79 patients 35.1%) the tumour was closely excised and in a few cases biopsied before the patients underwent radical surgery. 146 patients were radically operated primarily. These two groups of patients are comparable with regard to sex, distribution of tumours on anatomical sites and the distribution of tumours with a given histological classification. We have ascertained that neither excision biopsy nor non-radical operation influences the prognosis if followed by radical operation within about 3 weeks.

Primary melanoma of skin of the breast region

Primary melanoma of skin of the breast region accounted for less than 5% of all malignant melanomas. During a two-year period, 12 patients were seen with these unique lesions. It appears that wide excision and prophylactic lymphadenectomy, including radical mastectomy, gave the best long-term local and regional control. Dissection of the internal mammary nodes did not seem to be beneficial. Pertinent literatures emphasizing several important pathological factors which correlate with higher incidence of metastases to the regional lymph nodes are reviewed. A rational therapeutic approach, synthesizing above information and incorporating postoperative adjuvant immunotherapy, is suggested.

Results of BCG adjuvant immunotherapy for melanoma of the head and neck

The present study was performed to determine if postoperative systemic BCG adjuvant immunotherapy would improve survival in patients with pathologic stage II melanoma of the head and neck. Seventeen of twenty-five (68 per cent) patients treated with BCG are free of disease, whereas only seven of seventeen (40 per cent) patients treated by radical neck dissection alone are free of disease. Clark's technic for determining the level of invasion of the primary lesion was used to predict the presence of metastatic tumor in regional lymph nodes. Results indicate that patients with pathologically confirmed lymph node metastases from melanoma of the head and neck benefit from postoperative BCG adjuvant immunotherapy.

Present status of surgical management of malignant melanoma

Malignant melanoma has a distinctive appearance and has been clinically and histologically classified by Clark and Mihm. Using this classification a rationale for the surgical treatment of melanoma has been developed at the New York University Medical Center. The choice and extent of surgery is described. Early detection of melanoma and prompt surgical attention can significantly reduce the mortality from this neoplasm.